For both commercial health insurance plans and government-sponsored programs, COVID-19 tests and vaccines are a mandatory benefit according to federal rules. Although the messaging to consumers is that tests and vaccines are free, coordination of benefits expectations exist no matter where tests or vaccines are administered.
HMS recently worked with the New Mexico Department of Health to maximize insurance coverage for COVID-19 testing. The lessons learned from this partnership may be useful for other states that are navigating these waters.
Electronic Data Collection and Partnerships: Two Keys to Success in New Mexico
New Mexico has been a leader in terms of the COVID-19 response. It was the first state to have greater than 50% of adults who received at least one vaccine dose. Even before the vaccine rollout, the governor asked the New Mexico Department of Health (NMDOH) to develop a system to manage the volume of testing conducted statewide and to measure performance. The goal was to maximize data collection and efficient reporting, with minimal effort.
The registration tool for data collection enabled the state to track and capture clinical data, while capturing revenue to offset state expenditures for COVID-19 testing. Even with the electronic system in place, however, New Mexico was only capturing 30% of patient data with insurance information. Another solution was needed to capture potential revenue for the other 70% of patients.
NMDOH conducted manual reviews of eligibility information to capture Medicaid coverage. The team then worked with the Medicaid systems group to develop an interface for clients who had been tested for COVID-19, but didn’t provide insurance information. That captured payer information for 40% of the individuals.
Since HMS was already assisting New Mexico’s Medicaid program with coordination of benefits, NMDOH also decided to turn to HMS to identify primary payer data for clients that Medicaid was unable to capture. For this remaining population, HMS captured data for over 30% of the people which enabled the state to collect revenue for those individuals.
The last part of the pandemic-related revenue capture puzzle related to the federal government’s process to bill uninsured clients for testing and vaccines. This process was developed by the U.S. Health Resources & Services Administration (HRSA). The team at NMDOH was concerned that if they billed HRSA and later discovered that clients were insured, they would run the risk of recoupment. Fortunately, the HMS process eliminated that danger since all efforts to identify payer information were made and exhausted.
Electronic data capture capabilities played a critical role in NMDOH’s success. They allowed the team to work with large data sets in an automated way, rather than grappling with manual processes.
Thanks to these measures, the State of New Mexico went from a 30% capture rate for COVID-19 testing claims to nearly 90%. This has been a huge success in terms of revenue collection and offsetting expenditures related to testing. The state plans to use the same procedures to collect revenues for COVID-19 vaccines.
Best Practices for Navigating Public Health Crises
New Mexico’s experience during the COVID-19 pandemic has highlighted five lessons learned that other states can utilize today, as well as during future public health emergencies:
- Maximize insurance coverage. Even now, it’s not too late to maximize insurance coverage for COVID-19 testing and vaccines. There’s a substantial amount of savings to be had. In addition, proactively seeking out payments from payers is a defensive move, in case you are subject to a state or federal audit.
- Leverage private-public sector partnerships. These include working with insurance and Medicaid agencies, as well as private sector partners with subject matter expertise like HMS.
- Assess the continuity and applicability of COVID-related responses. Many pandemic programs have lasting power and relevance for other public health initiatives. The application developed by NMDOH will be carried over into other programs and outreach settings, such as flu shot and school immunization events.
- Maintain public health and Medicaid continuity. The pandemic has fostered unprecedented levels of collaboration across different stakeholder groups. This aided with crisis response, but those relationships will continue to be valuable even as COVID-19 wanes.
- Develop a preparedness roadmap. Emergency preparedness allows organizations to quickly and efficiently respond to crises as they arise.
The opportunity to maximize insurance coverage for COVID-19 related services is immense. Over 800 million tests and more than 275 million vaccines have been administered. By July 4th, 2021, the United States has set a goal that 70% of Americans will be vaccinated for COVID-19.
There’s never been a better time for states to examine their coordination of benefits processes and make improvements. If you’d like to learn more about how HMS can help, feel free to contact us.